Study protocol - Ascertaining the career Intentions of UK Medical Students (AIMS) post-graduation: a cross-sectional survey

doi:10.21203/rs.3.rs-2475578/v1

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Study protocol

Study protocol - Ascertaining the career Intentions of UK Medical Students (AIMS) post-graduation: a cross-sectional survey

https://doi.org/10.21203/rs.3.rs-2475578/v1

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Background

Among doctors in the United Kingdom, there is growing sentiment regarding delaying specialist training, emigrating to practice medicine abroad, or leaving the profession altogether. This may have significant implications for the future of the profession in the UK. The extent to which this sentiment is also present in the medical student population is unknown.

Methods

The AIMS study is a national, multi-institution, cross-sectional study of all medical students at all medical schools in the United Kingdom. It will be administered via an online questionnaire and disseminated through a collaborative network recruited for this purpose. Our primary outcome is to determine current medical students’ career intentions after graduation and upon completing the Foundation Programme, and to establish the motivations behind these intentions. Secondary outcomes include determining which, if any, demographic factors alter the propensity to pursue different career paths available to a medical graduate, determining which specialties medical students plan on pursuing and understanding current views on the prospect of working in the National Health Service (NHS). Both quantitative analysis and thematic analysis will be used.

Discussion

Doctors’ career satisfaction within the NHS is a well-researched topic, however, there is a shortage of high-powered studies able to offer insight into medical students’ outlook on their future careers. It is anticipated that the results from this study will bring clarity to this issue. Identified areas of improvement in medical training or within the NHS could be targeted to improve doctors' working conditions and help retain medical graduates. Results may also aid future workforce planning efforts.

Trial Registration:

Not Applicable.

Medical Students

NHS

Career Intentions

Attitudes and Opinions

Workforce Planning

Medical Education

In the United Kingdom, medical degrees typically last for 5 or 6 years, depending on whether one elects to pursue an additional year in the awarding of an intercalated degree. Alternatively, for previous degree holders, there is a 4-year accelerated medicine course. Presently, upon completion of their medical degree, graduates are provisionally registered with the General Medical Council (GMC). Graduates then enter the mandatory two-year UK Foundation Programme (UKFP), consisting of rotations in various settings and specialties. At the end of their first year of the UKFP, they are awarded full medical registration with the GMC. Doctors who have completed the UKFP are then able to pursue further training, which may be very specialised, for example, in ophthalmology or neurosurgery, or broader pathways such as in general practice or internal medicine training (1).

Historically, the vast majority of UKFP graduates pursued specialty training immediately after completing their foundation programme, for instance, in 2010, the proportion was 83.1% entering further training upon completing Foundation Year 2 (F2). However, the UK Foundation Programme Office (UKFPO) career destination report revealed that this number had fallen to only 34.9% of doctors in 2019 (2). The UKFPO has not repeated the survey since then, so it is difficult to surmise how these statistics may have changed in the interim.

In comparison to most other Organisation for Economic Co-operation and Development (OECD) countries, the UK has fewer doctors per population (3). One of the ways the British government has attempted to combat this issue is through the opening of new medical schools as well as increasing student capacity in existing medical schools (4, 5). It is our aim to understand the effectiveness of this approach, are the factors encouraging graduate doctors to seek alternatives to medicine in the UK, or in its entirety, also present in the undergraduate population?

AIMS also endeavours to investigate the reasons behind students’ intentions to both enter and leave the standard training pathway and attempt to identify any demographic and background information which might increase the propensity to leave training.

A BMA survey of 8,000 senior doctors determined that 44% of National Health Service (NHS) consultants in England plan to leave or take a break from working in the NHS over the next year (6). Similarly, a recent survey of 4,553 junior doctors in the NHS reported that 4 in 10 plan to leave the NHS, with 33% of these wanting to emigrate to another country to work (7). Broader literature supports these findings, with a 40-year survey series of junior doctors highlighting that the desire to remain in UK medical practice was lower in 2015 than had ever been recorded (8). Additionally, in 2021 nearly 10,000 doctors relinquished their licence to practice in the UK, making up nearly 1/10 of its total doctor workforce (5, 9). We aim to determine if this trend, found in both junior and senior doctors alike, may also manifest in the intentions of medical students yet to even enter the profession.

The study invites participants to share their views on many aspects of working in the NHS and how the prospect of working in the NHS could be improved. Data collected from this study could prove helpful in addressing some of the concerns of those making up the future of the profession. In Australia and New Zealand, a survey is distributed each year, where the Medical Deans of medical schools in the country survey final-year medical students and data is collected on their background, medical school experience, and any early geographical and specialty preferences for their future career (10). The information gained has had a lasting positive impact on curriculum development and future medical workforce planning. Additionally, it has assisted in workforce distribution and helped to plan specialist training pathways to meet the career interests of trainees and the public’s health needs.

The AIMS study is a national, multi-institution, cross-sectional study. AIMS endeavours to understand the factors involved in medical students' decision-making around their future careers. Specifically, we are interested in students' current career plans and why they may or may not intend to pursue specialty training, or a medical career, in the UK. We are also hoping to understand current views on the prospect of working in the NHS.

Study Objectives

Primary objectives

To determine current medical students’ career intentions after graduation and upon completing the Foundation Programme (FP), and to ascertain the motivations behind these intentions

Secondary objectives

To characterise the backgrounds of medical students intending to:
- emigrate to practice abroad
- leave medicine permanently
- undertake further study/career break
- not going into further medical training immediately after degree completion/foundation training
To determine which specialties medical students plan on pursuing.
To analyse medical students’ views on how the prospect of working in the NHS could be improved.

AIMS is a national, multi-centre, cross-sectional study of medical students. Participants’ responses will be recorded via an online survey platform. The survey contains 71 items, but no participants will view all items, it is dependent on the answers they give. The shortest question sequence involves 30 items, and the longest involves 43 items. Questions are structured using a combination of Likert scale matrices, multiple-choice options, and free-text entry to broaden the capture of sentiment nuance and improve precision in the data. Data collection will take place from the 16^th of January 2023, aiming to be completed on the 27^th of March 2023.

Part 1 of the survey involves a background and demographic section, which all participants will answer. Part 2 then focuses on career intentions immediately after graduation and after foundation training (for those entering). Part 3 invites participants to explore the factors behind their decision-making. Part 4 surveys which specialties the participants are currently inclined to pursue. The final part includes a free-entry text box where participants are invited to articulate how the prospect of working in the NHS could be improved and to obtain consent for follow-up.

The full 71 item questionnaire can be found in the Online Supplemental Materials.

To identify gaps in knowledge and inform the aim of the project, a review of existing literature was conducted, including similar questionnaires and qualitative studies on students’ perspectives. Feedback from senior clinical staff was also obtained. Questions were revised based on these reviewer comments to make them as non-directive as possible.

The survey will be hosted on the Qualtrics survey platform (Provo, Utah, USA), a GDPR-compliant online survey platform that supports mobile and desktop devices. The survey will be distributed through university mailing lists, student society pages, conferences, and personal and medical school social media platforms (such as Facebook, Instagram, LinkedIn, and Twitter). To maximize distribution across the UK, a national network of AIMS Collaborative members was recruited, representing all medical schools in the UK. Each member was asked to coordinate with their medical school dean to distribute the survey through official channels and regularly advertise it over the collection period from January to March.

A Participant Information Sheet (PIS) will be made available to all participants (available in the Online Supplemental Materials). This will explain the rationale, purpose, and voluntary nature of participation in the study. It will also emphasize that participation is anonymous, confidential, and voluntary and that participants can withdraw their consent at any time. Participants will be informed via the original advertisement leaflets and the front page of the survey that by submitting their answers, they consent for their data to be used. Email addresses will only be collected from participants who explicitly consent to this through the final question of the survey.

All data will be collected and stored on the secure online server Qualtrics. Survey data will be extracted from the software to a password-protected Microsoft Excel spreadsheet (Microsoft, California, USA) only available to the central study team. The University of Cambridge's standards for data security will be followed for all data handling and record keeping.

Study population

All current students of all years at UK medical schools recognized by the GMC and the Medical Schools Council are eligible to participate in the study. A list of eligible medical schools and approved programs can be found in the Online Supplemental Materials. It is worth noting that we have excluded schools that, although approved by the GMC, have not yet accepted their first cohort of students, and thus have no medical students to participate.

Data collection

The survey will be disseminated primarily through recruited medical student collaborators recruited prior to the study launch. Collaborators will ensure that their medical school is formally engaged at an early stage of this study. They will be primarily responsible for disseminating this questionnaire among students at their medical school.

Financial prize

At the end of data collection, a prize draw will be held for participants who have opted to provide their contact details. Two randomly selected participants will be selected at random to receive £50 in Amazon vouchers.

Data Analysis

A sample size calculation was performed, and it was determined that a minimum of 8,026 participants are needed to have a confidence level of 95% that the results of the survey are within ±1% representation of the total medical student population. This calculation used a population size for UK medical students acquired via a Freedom of Information request to the GMC.

The STROBE cross-sectional study guidelines will be followed for this study (11). Descriptive statistics and comparisons between student year groups and other participant characteristics will be used. Appropriate statistical tests will be applied for these comparisons. For free-text questions from which qualitative data will be obtained, a thematic analysis will be carried out using the reflexive approach of Braun and Clarke (12).

After Study Completion

Following study completion, teleconferences will be held with all collaborators to share and discuss the data analysis undertaken and the study results. Following this, the results will be presented at local, regional, national and international conferences. In addition, the results will be disseminated via publication in a peer-reviewed medical journal. All collaborators will be given PubMed-citable collaborative coauthorship under the institutional name ‘AIMS Collaborative’. We will have a hybrid authorship list of named authors and the institutional collaborative.

Medical school collaborators will be able to request their institution’s specific data and the analysis done on said data from the AIMS steering committee following study completion. This data will be anonymised. The fully anonymised data set will be made publicly available.

Table 1 - Project timeline. This timeline will be approached with a level of flexibility, such as for centres with logistical obstacles to data collection.

Dates	Activity
12 December 2022 - 9 January 2023	Recruitment of collaborators throughout all UK medical schools via social media and communication with medical schools/societies.
10 January 2023 - 15 January 2023	Training of collaborators
16 January 2023 - 27 March 2023	Study runs nationally for 2 months
28 March 2023 - 1 October 2023	Data analysis and manuscript preparation

While there have been: i) studies exploring which specialties junior doctors or medical students intend on pursuing (13, 14, 15, 16, 17, 18), ii) studies which focused on career intentions of those pursuing one specialty or exploring factors that attract them to one specific specialty (19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35), iii) studies specifically focused on reasons why doctors are leaving the UK (36, 37, 38, 39, 40), iv) studies exploring how medical students and junior doctors feel about specific aspects of working within the NHS (41, 42, 43, 44), v) studies investigating the desire for a career break post-foundation year 2 (also known as the ‘F3’) (45, 46, 47), there have been no recent, high-powered studies explicitly aimed at medical students, irrespective of current career ambitions or seniority, investigating overall career intentions and correlating it with demographic factors and medical student seniority. There has been one similar study, although focusing entirely on medical students and their intentions to leave the NHS, which is limited by its low power and lack of subanalysis regarding student seniority and demographic factor (48). We aim to address these limitations. Additionally, this study will be the first of a series of follow-up surveys of medical students, thus being the first medical students’ career intentions longitudinal study of its kind.

Strengths

Owing to its rigorous collaborator recruitment plans in hopes of high participant recruitment, this study will accurately demonstrate medical student intentions to either remain in the UK to practice or to go abroad as well as their specialty of choice – this could prove useful for workforce planning.
The study will determine the current undergraduate consensus on several aspects of working in the NHS, which could help future policymakers prioritise change and better help medical schools prepare their junior students for the reality of such aspects.
This study will determine which, if any, demographic factors alter the propensity to pursue different career paths available to a medical graduate.

Limitations

The study is limited by its snapshot nature, as we cannot see how career intentions have or will change over time. However, it is our intention to follow up with consenting participants and determine how their career intentions may have changed.
It is possible that those already intending to exit the profession, to emigrate, or those disgruntled with the current circumstances will be more likely to complete the survey. To mitigate this, we will recruit over 150 collaborators who will distribute the survey in their respective medical schools, targeting all medical students. Additionally, the promotional material and the questions have been written not to imply any particular outcome is predicted or sought.
It is possible that there might be challenges to the recruitment of collaborators or to the uptake of student responses which could jeopardise the study’s national goals.

This study presents a unique opportunity to accurately assess how medical students view their current career prospects and assess the feasibility of potentially implementing a regular, census-like survey of UK medical students to assist the government’s efforts in workforce planning and addressing grievances within the workforce, therefore resulting in higher job satisfaction.

Ethics approval and consent to participate

Ethical approval was granted by the University of Cambridge Research Ethics Committee (reference PRE.2022.124) on the 5th of January 2023.

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and/or analysed during the current study will be made publicly available due once the study is completed.

Competing interests

The authors declare that they have no competing interests.

Funding

Queens’ College, University of Cambridge. The institution has had no role in the design of the study, and collection, analysis, and interpretation of data and in writing the manuscript.

Authors' contributions

TF responsible for conceptualisation. TF responsible for obtaining funding and ethical approval. TF responsible for drafting the manuscript. TF and AMC responsible for designing the survey. All authors responsible for editing and revising the manuscript. RH responsible for supervision. All authors have read and approved the manuscript.

Acknowledgements

Not applicable.

Authors' information (optional)

Not applicable.

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No competing interests reported.

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Study protocol - Ascertaining the career Intentions of UK Medical Students (AIMS) post-graduation: a cross-sectional survey

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